Never Events in nursing are serious, preventable errors or incidents that should never occur in healthcare. They result in severe harm or death and are considered avoidable. The AHRQ & National Quality Forum have a list consisting of 29 "serious reportable events" grouped into seven categories:
It goes without saying that virtual reality (VR) isn’t a fix-all for Never Events. Addressing and preventing them requires a comprehensive approach from all angles. However, here are some ways immersive VR can help.
VR simulations can recreate complex healthcare environments, enabling nurses and learners to experience and navigate various scenarios, such as a patient with pyelonephritis. By improving their situational awareness, they can better identify potential risks and take proactive measures to prevent Never Events.
With UbiSim, nurse educators and hospitals can customize scenarios with our intuitive Editor. There are ready-made scenarios, too, and scenarios created by other nurse educators and hospitals are shared within our Community.
Immersive VR can facilitate team-based training, enabling nurses to collaborate and communicate effectively in simulated healthcare settings. By practicing interprofessional teamwork, nurses can enhance their coordination and communication skills, crucial for preventing Never Events.
With UbiSim, nurses and nurse learners can peer-facilitate, helping them learn from one another. We also have a multiplayer mode where they can work together to help a virtual patient.
VR-based training can provide ongoing opportunities for nurses in hospitals to enhance their skills and knowledge related to patient safety. By engaging in regular VR simulations and debriefing sessions, nurses can identify areas for improvement and implement changes in their practice.
VR can simulate various patient conditions, presenting nurses with lifelike scenarios where errors or critical situations are intentionally introduced. This allows nurses to practice recognizing these errors promptly and responding appropriately, improving their ability to mitigate risks and prevent Never Events.
With UbiSim’s intuitive Editor, it is possible to create a "Room of Errors" where learners can perform a physical and environmental assessment and note the errors in the room. Some of these errors include:
Patient death or serious injury associated with unsafe administration of blood products
UbiSim has multiple scenarios that train nurse learners on blood administration and recognizing/responding to transfusion reactions. This is a skill that student nurses cannot practice in clinical placements because they must have a license to administer blood.
Patient death or serious injury associated with a medication error
UbiSim scenarios allow learners to perform necessary dosage calculations and practice the five rights of medication administration. Our software captures if the learner verifies the name band and administers the correct dose/route/time/rate, etc.
Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results
Learners receive real-time lab results that should be communicated to the provider via SBAR communication. Failure to communicate these critical results may lead to a patient's decline.
Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a healthcare setting
Using bedrails correctly is a fundamental skill that matters. Our bed rails in UbiSim are functional, and learners are able to identify whether having all four side rails up is appropriate or inappropriate in a given scenario. This is important because using all side rails up can be considered a restraint, and in some circumstances, patients who are experiencing confusion or other conditions can get seriously injured by trying to exit the bed.
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